Margaret McCartney: Nuclear weapons do harm, even if never used

All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

There is no room to disagree that nuclear weapons are the greatest artificial means to destroy mankind and make the earth ruin1. Besides nuclear weapons, chemical weapons can also be a means to destroy mankind2. Organophosphorus compounds used in agriculture can also function as weapons3. If they are mounted on a rocket and dropped or scattered on hostile destinations in an accurate orbit, they have enough power to damage the human race in the area. In order to protect ourselves from such weapons installed in rockets, it is recommended to evacuate to the basement and protect ourselves from them. Subway station and underpass can function as nuclear shelters.

However, the circumstances were different in the Tokyo subway incident in Japan in 1995. The Tokyo subway sarin attack in 1995 was the first large-scale disaster caused by the nerve gas sarin3, which causes the clinical syndrome of cholinergic hyper-stimulation by inhibition of the crucial enzyme acetylcholinesterase. A religious cult released sarin gas into subway commuter trains during the morning rush hour. On that day, the patient was getting on the vehicle of the subway where the incident occurred, heading for the company of his office. Liquid was spilling on the floor of the vehicle, which caused a pungent odor. His arms and feet trembled with wiggles and he could not stand. He could not breathe and his consciousness went away. He noticed that he himself was on the bed of the emergency and life center intensive care unit. Both of his both pupils were constricted to 1.5 mm like pinpoints. He was vomiting and profusely sweating, and he had increased oral and nasal secretion. Because of these characteristic signs of organophosphorus intoxication4, amount of atropine sulfate and pralidoxime iodide were intravenously administered5. Both prominent ST elevation of V3-6 on the 12 lead electrocardiogram and protrusion out of the apical ventricle on the echocardiogram at the first visit to the emergency unit, returned normal within 10 days of treatment. During the treatment, no rise in cardiogenic enzymes such as creatine phosphokinase was observed, no lethal arrhythmia was seen, and blood pressure was maintained. He was diagnosed as Takotsubo cardiomyopathy, which has a character of transient, reversible left ventricular dysfunction with normal coronary arteries6,7. Acute physical or emotional distress, such as unexpected sarin attack, is thought to play a role in the development of Takotsubo cardiomyopathy through sudden vigorous sympathetic stimulation. We also have reported a case of combination with Takotsubo cardiomyopathy and amnesia7,8. Takotsubo cardiomyopathy and transient global amnesia are sometimes reversible but sometimes irreversible disorders that can occur concurrently partially due to catecholamine excess, leading to pathophysiological changes within the brain and the myocardium.

It is terrorism itself, such as spreading highly toxic organic phosphorus compound like sarin in the subway on which an unspecified number of passengers are on board. Even now that more than 20 years have elapsed, we must not forget that the subway station premises in Tokyo, which is expected as a shelter for nuclear attacks, were used in the crime scene.

Dr McCartney’s admitted forgetfulness about her student membership of the Medical Campaign against Nuclear Weapons perhaps explains her view of the purpose of IPPNW.

IPPNW was a Soviet front organization whose purpose was not ‘to present the medical case for preventing nuclear war’ – there is plenty of such appalling evidence from Hiroshima and Nagasaki – but to call for unilateral disarmament by the west. Fortunately, in this treasonous quest it failed.

I drew attention to all this, with references, in a letter published in the BMJ as long ago as 1991(1).

Sir,
The escalating crisis between the USA and North Korea illustrates the major problem with MAD (mutually assured destruction) as a strategy: it depends on a rational assessment of the terrible risks for the world of the use of nuclear weapons. This assessment should then lead to diplomacy, behaviours and decisions calculated to avoid such a catastrophic event. There is little sign at present of such a rational assessment, which is deeply worrying for all of us.

If nuclear weapons are used, the consequences fall mainly on non-combatants. In this sense, nuclear weapons are similar to biological and chemical weapons, which are banned under international law. Our recent letter led by Dr Michael Orgel of MEDACT Scotland and co-signed by Nobel Laureate for Physics Professor Peter Higgs, sets out these arguments and the huge risks to human and planetary health of even a small nuclear exchange. This is likely to affect both hemispheres, not just the immediate area affected by radiation (1).

I would probably accept that the strategy of dependence on MAD may have helped to avoid global, although certainly not regional, conflict since World War 2. However, it is now time for a re-assessment. It is quite clear that the risks of nuclear weapons are growing, and are now much greater than any deterrent benefit. The UK has an opportunity for global and planetary leadership. It could sign the comprehensive treaty banning nuclear weapons agreed by 122 nations and adopted on 7th July 2017 at the UN.

McCartney makes the controversial claim that “Even if the nuclear weapons are never used, they do harm.”[1].

The whole point of a strategic nuclear deterrent is to deter any enemy from considering a nuclear first strike, a strategy predicated on the concept of mutually assured destruction (MAD). Given that no nuclear weapons have been used in anger since the end of World War Two and that we are alive to have this debate is testament to the success of the nuclear deterrent, including Britain’s Trident missile system.

The absence of any use of nuclear weapons in the last 72 years can hardly be considered a harm. Quite the opposite in fact. The Cold War stayed “cold” precisely because both the North Atlantic Treaty Organisation (NATO) and the Soviet Union possessed a credible nuclear arsenal. The concept of MAD worked then and continues to work today.

McCartney and the nuclear disarmament lobby ignore the fact that whether they like it or not, the UK’s Trident system provides ongoing employment of approximately 7,000 people in Scotland (4,700 military, 2,250 civilian) and between 30,000 and 40,000 jobs across the UK[2,3]. The fact that the UK strategic nuclear deterrent supports tens of thousands of long-term jobs, including highly skilled ones, cannot be seen as “harmful”.

Finally, McCartney refers to the £31 billion cost of renewing the Trident missile system. The new Trident submarines will be expected to serve for over 30 years once they are introduced. The current quartet of Vanguard class nuclear submarines entered service in c. 1992[4]. They have already been in continuous service (in rotation) for a quarter of a century, defending us against strategic nuclear threats on a 24/7 basis.

They will only be replaced by their successors, the Dreadnought class ballistic missile submarines from the early 2030s[5]. The new Trident submarines will have very long service lives and the procurement costs must be viewed in this context.

As McCartney rightly points out, we live in an increasingly complex geopolitical environment. North Korea is racing to develop nuclear-armed intercontinental ballistic missiles (ICBM), which have the range to reach the United States and Europe[6,7]. Now is absolutely not the time to be arguing against the maintenance and renewal of Britain’s strategic nuclear deterrent. To abandon Trident now would be to put ideology before national security at a time when the international nuclear threat landscape is growing more hostile, not less.

I would prefer that we did not need a strategic nuclear deterrent and indeed that nuclear weapons did not exist. However, the nuclear Pandora’s Box has been opened and we don’t live in Utopia. To abandon Trident now would be injurious to national security. I am relieved that the British Parliament approved the renewal of the Trident nuclear system in 2016 by a significant majority[8].

Andrew makes the breathtaking claim that "Historical evidence shows that no nations with nuclear weapons have engaged in war (the practice of putting young men at risk to support the aspirations of older politicians) since Nagasaki.". I presume he meant to add "With each other"? But what of the Korean War, when Russian Migs fought US jets, and Chinese troops fought US troops, and MacArthur was forcibly retired after advocating nuclear escalation?? So his premise is thankfully mistaken. Thankfully I say, because it were true, then he has argued the perfect case for North Korea and all other nations to obtain nuclear weapons, in their belief that it will deter war between States forever. Some mistake, Andrew, surely??

Scotland does commission services like England: it is England that have seen swathes of restrictions to enforce cuts to budgets. Cuts are managed by waits in Scotland -locally physiotherapy waits are now 8-9 months. Many surgical operations have targets of 12 week waits but are not being done for 9-12m.

It is possible to be grateful to members of the military for their service but to also disagree with the presence of nuclear weapons.

Most weeks Margaret McCartney cites the importance of evidence in her campaigns to avoid change by such iniquities as medical innovation. What a surprise to see her ditch her normal evidential discipline to promote faith in her political preconceptions.
Historical evidence shows that no nations with nuclear weapons have engaged in war (the practice of putting young men at risk to support the aspirations of older politicians) since Nagasaki. Are her opinions, formed as a medical student in the late 1980's, based on evidence or opinion? By the time she indulged her own freedom of speech I had served in hospital ships in a non-nuclear war in the South Atlantic and cared for "soldiers" including Argentinian schoolboys for the benefit of the freedom of Falkland Islanders. At the time I rationalised (and I still do) that it is worthwhile to die for the freedom of one's fellow man: I volunteered to put myself into the face of danger eight thousand miles from home. Later I served in Submarines for three months at a time and thought long and hard about the ethics of nuclear deterrence: historical evidence convinced me of the benefit of deterrence.
When she next cycles along Loch Long, perhaps Dr McCartney might consider the evidence that shows beyond reasonable doubt that, in the conventional warfare she apparently prefers, it is young men who die and are maimed while in nuclear exchanges, the politicians would also pay the price (hence no weapon has been used). Brave young American, British And Russian men serve in the depths of the oceans to ensure that she can peddle her myths of monolateral joint and cataract treatment.
Banning nuclear weapons from those who dare not use them would simply permit rogue states like North Korea to cause mayhem. Is it not irresponsible to to take any other view or should we also support the "freedom fighters" who leave bombs on tube trains and buses to maim our patients indiscriminately?
To consider nuclear weapons as "never used" is to misrepresent the philosophy of deterrence so eloquently described as Mutual Assured Destruction (MAD) by Robert McNamara whose grave lies largely unnoticed in Arlington Cemetery about 100 yards from that of JFK. Every moment a deterrent (of East of West) is deployed and not fired it is being used to keep the peace in preventing bullets from disrupting the chests of soldiers and front-line civilians who are human beings, just like Dr McCartney and her patients.
Isn't it time the Editor of the BMJ started editing her journal? She might start by seeking evidence from Dr McCartney on monolaterality of joint replacement and cataract treatment in Scotland which is not the experience of my (Scottish) patients. If the evidence is not produced, perhaps Dr McCartney's contract might be reviewed on the basis that my former military constituents are BMA members and therefore shareholders of the company that pays the Editor's wages and whose contributions are belittled by uninformed political posturing.
If this rapid response is published, Dr McCartney should immediately cite the evidence (not simply her report) that pensioners are told "there's only enough money to take out one cataract"; otherwise the Editor should fulfil her duty to BMA members to ensure that the BMJ is "Evidence Based".

Competing interests:
I am a former Armed Forces Doctors Representative on BMA Council. I have served in conventional conflict and in the Cold War. I have been a member of the BMA Armed Forces Committee

McCartney questioned why the UK didn’t turn up to a UN vote in July to approve banning nuclear weapons.(1) This is wiser than the Zarocostas’ naïve enthusiasm commending an “historic milestone” but deserves comment(2)

First, since the 1955 Russell–Einstein Manifesto, the UN bureaucracy has been issued several treaties (Partial Nuclear Test Ban in 1963, Non-Proliferation of Nuclear Weapons in 1968). However, no action despite recurrent breaches: a) there are now 14 states with, or sharing, nuclear weapons. Worst, modernisation of weapons continues.(3) b) in 2016, the UK House of Commons voted to renew the British nuclear weapons with the Dreadnought-class submarines; c) the world share of the French nuclear arsenal has increased steadily from 0.1% at the height of the Cold War in 1966 to 1% in 1991 and reached 1.9% in 2016.(http://www.ifrap.org/etat-et-collectivites/quelles-evolutions-pour-la-di...) In 2015, President Francois Hollande stressed the need for a nuclear deterrent in "a dangerous world".

Second, in 1991, Ukraine inherited 5,000 nuclear weapons from the Soviet Union, making its arsenal the third-largest in the world. In 1994, Ukraine adhered to the Treaty on the Non-Proliferation with the condition that its borders were respected.(Budapest Memorandum on Security Assurances) All nuclear weapons were disassembled in Russia in 1996. On 18 March 2014, after a military intervention, Russia annexed the Ukrainian territory of Crimea and the city of Sevastopol administering them, de facto, as the Crimean Federal District. Now Russia is also running militant-controlled parts of east Ukraine. UN-treaties are scraps of paper. Crudely put, those relying on UN are terminally screwed.

I guess UK didn’t turn up to the vote because UK does not want to put its head in the sand. Indeed, while soft diplomacy may be required as a first step, here it was a slippery slope from complacency to complicity. Last, as a clinician, my first concern is about another UN treaty: The Framework Convention on Tobacco Control. Indeed, tobacco kills more than nuclear weapons and this UN treaty is also a smokescreen.(4)

The global peace is as old as the nuclear weapons (NW). The difference between nuclear and conventional weapons is well known: the use of the formers would spoil the winners’ triumph due to the extensive radioactive contamination, long term health and environmental cost to humans and the planet [1]. This is the probable reason why some bellicose leaders advocated nuclear disarmament. Deterrence by credible threat of retaliation is another peace-preserving mechanism enhanced by NW [2]. The presence of NW has apparently contributed to responsibility of political and military decisions. The nuclear industry must be managed by a powerful international executive based in the most developed parts of the world. It would prevent from spreading of nuclear technologies to unstable regions, where wars and terrorism are not excluded. For example, the only thinkable way to peace in the Middle East is a direct rule by an international executive based in developed countries. Especially in the desert areas, the birth rate must be restricted. NW is an ultimate tool for security [3] and, probably, the last hope for the global peace. The nuclear abatement would not contribute to prevention of large-scale wars that have repeated during the whole history. It would be more reasonable to preserve NW, to develop nuclear technology, to limit military expenditures as far as reasonably possible, and to foster international trust, cooperation and tourism. Mistrust and suspicion can form a vicious circle of heightening tension potentially contributing to international conflicts. Unfair practices and fraud in international relations, ideological biases and hidden conflicts of interest must be exposed and eradicated. Religious motives of terrorism and war propaganda must be regarded as aggravating circumstances in the criminal justice. Moral principles based on mercy and forgiveness, modesty, mutual help and birth control, aimed at preservation of as much life, wealth and human rights as possible, should be propagated instead. The best means against militarism is a compulsory preservation of peace, while NW is an efficient tool for this purpose. Let the militarists spend their money on conventional weapons that will be never used - thanks to the nuclear deterrence. This is the only thinkable way to defend civilization from barbarism. More details and references are in [4].
References
1. McCartney M. Nuclear weapons do harm, even if never used. BMJ 2017;358:j3978
2. Cimbala SJ. Arms for uncertainty: nuclear weapons in US and Russian security policy. Burlington, Vermont: Ashgate, 2013.
3. Nuclear weapons, energy, and nonproliferation: pressures on the global community. 41st Conference on the United Nations of the Next Decade. June 16-21, 2006, Enchantment Resort, Sedonia, Arizona.
4. Jargin SV. Nuclear Facilities and Nuclear Weapons as a Guarantee of Peace. J Def Manag 2016;6:146 https://www.researchgate.net/publication/303051342_Nuclear_facilities_an...